<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
<head>
<meta http-equiv="Content-Type" content="text/html; charset=utf-8" />
<meta name = "viewport" content = "width = 1280">
<title>Payment</title>
<link rel="stylesheet" href="../../style.css" media="screen" />
<link rel="stylesheet" href="../../scripts/jquery.ui/theme/smoothness/jquery-ui-1.8.6.custom.css" media="screen" />
<link rel="stylesheet" href="../../css/register.css" media="screen" />
<link rel="stylesheet" href="../../scripts/jquery.validate/validate.css" media="screen" />
<script type="text/javascript" src="../../scripts/jquery.min.js"></script>
<script type="text/javascript" src="../../scripts/jquery.ui.min.js"></script>
<script type="text/javascript" src="../../scripts/jquery.easing.1.3.js"></script>
<script type="text/javascript" src="../../scripts/jquery.validate.min.js"></script>
<script type="text/javascript" src="../../scripts/jquery.ui.min.js"></script>
<script type="text/javascript" src="../../scripts/common.js"></script>
<!--<script type="text/javascript" src="../../scripts/jquery.ui/timepicker.js"></script>-->
<script type="text/javascript" src="../../scripts/jquery.ui/jquery.timepicker.js"></script>
<script type="text/javascript" src="../../scripts/cufon/cufon-yui.js"></script>
<script type="text/javascript" src="../../scripts/cufon/PSL_Kittithada_Pro___700.font.js"></script>
<script type="text/javascript">
Cufon.replace('h2');
Cufon.replace('h3');
Cufon.replace('label');
$(function(){
	$('#date').datepicker({dateFormat: 'yy-mm-dd', 
	    duration: '',  
        showTime: true,  
        constrainInput: false,  
        stepMinutes: 1,  
        stepHours: 1,  
        altTimeField: '',
        time24h: true  }).attr('autocomplete', 'off');
});
</script>
<style type="text/css">
html, body {
	overflow: hidden;
}
</style>
</head>
<body id="register">
<!--$header_html-->
<div class="shadow-l"></div>
<div class="shadow-r"></div>
<div id="wrap-container" class="bg-type1">
  <div class="content">
    <h2>แจ้งชำระเงิน</h2>
    <div class="register-form">
      <form action="" method="post" name="form-register" id="form-register" enctype="multipart/form-data">
        <div class="account-info">
          <h3>วีธีการชำระเงิน/แจ้งว่าชำระเงินแล้ว</h3>
          <ul>
            <li>
              <label>หมายเลขสั่งซื้อ </label>
              <input type="text" name="order_number" value="" />
            </li>
            <li>
              <label>Reference </label>
              <input type="text" name="reference" value="" />
            </li>
            <li>
              <label>ชื่อ-สกุล </label>
              <input type="text" name="name" value="" />
            </li>
            <li>
              <label>อีเมลล์ </label>
              <input type="text" name="email" value="" />
            </li>
            <li>
              <label>เบอร์โทรศัพท์</label>
              <input type="text" name="telephone" value="" />
            </li>
            <li>
              <label>จำนวนเงิน</label>
              <input type="text" name="total" value="" />
            </li>
            <li>
              <label>วันที่ชำระเงิน</label>
              <input type="text" name="date" id="date" value="" />
            </li>
            <li>
              <label>หมายเหตุ </label>
              <textarea name="description"></textarea>
            </li>
            <li>
              <label>รูป Slip </label>
              <input type="file" name="image" id="image" />
            </li>
            <li></li>
            <li></li>
            <li>
              <input type="submit" name="submit" value="submit" />
              <input type="reset" name="cancel" value="cancel" />
            </li>
          </ul>
        </div>
      </form>
      <br class="clear" />
    </div>
  </div>
 
</div>
<!--$footer_html-->
</body>
</html>